Interests / Hobbies Please list any skills, hobbies, or other activities that would contribute to your proficiency as a caregiver. Many 12- and 24-hour jobs include considerable amounts of unstructured time, and leisure time participation with the client is important. Please indicate activities you enjoy and/or are able to teach to someone else.

Medical Due to the fact we match client needs with caregiver abilities, please list any physical or mental limitations and/or impairments that would have a direct effect on providing care to clients. For example: cannot lift more than 10 pounds due to back/ On medication and cannot drive while taking it.

*Education

High school

College

Other

*Employment History

Carefully fill in the information below. Volunteer experience may be substituted if there is no employment history. In order to process your application, you must provide complete names and addresses of your employers. Without this information your application cannot be processed

Present or Most Recent Employer

Company Name

Company Phone #

Supervisor's Name

Supervisor's Phone #

Address:

City

State

Zip Code:

Employed from:

to

Reason for Leaving:

Company Name

Company Phone #

Supervisor's Name

Supervisor's Phone #

Address:

City

State

Zip Code:

Employed from:

to

Job Duties:

Reason for Leaving:

Company Name

Company Phone #

Supervisor's Name

Supervisor's Phone #

Address:

City

State

Zip Code:

Employed from:

to

Job Duties:

Reason for Leaving:

PERSONAL REFERENCES

A minimum of three (3) references, including complete mail addresses, is required.Do NOT use family members or past supervisors.

1 Name:

Full address:

Relationship

Telephone

2 Name:

Full address:

Relationship

Telephone

3 Name:

Full address:

Relationship

Telephone

*Availability Please put a check mark in the box of your availability

Days

AM

PM

ON CALLS

COMPANION

HOLIDAYS

Monday

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Tuesday

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Wednesday

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Thursday

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Friday

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Saturday

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###

Sunday

###

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###

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Caregiving requires a high degree of dependability. Describe why you feel you are dependable. Give Examples.

Tell Us about you

If your record shows that you have been convicted (in any state) of a crime that is equivalent to a crime on the list above or a crime that has been renamed, you may be disqualified or determinated

If a court, state department, disciplinary board, or dependency action has found that you have abuse, neglected, exploited, or sexually abused any minor or vulnerable adult, you are automatically disqualified from employment and/or placement through this organization.

If your record shows that you have been convicted of other crimes related to care of vulnerable adults or children, you may be disqualified from employment and/or placement through this organization.

Have you ever been arrested or convicted of any of the crimes listed above? YesNo

if Yes - Please describe:
I certify that information I have provided in this employment application is accurate and been completed to the best of my knowledge and ability. I understand that any falsification, misrepresentation or omission in my interviews or any other employment record, may be sufficient reason not to hire me or may be reason for dismissal.